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If medical journals are the religious texts that guide me as a physician, the New York Times has become the secular source of illumination for my relationship to my country and the world I live in.

That doesn’t exactly mean that I feel like a citizen of the world. Quite the opposite, particularly now, with just me and my horses sharing our existence on a peaceful plot of land within walking distance of the Canadian border; my physical world seems quite small even though I am aware, sometimes painfully but with an obvious distance, of the calamity of our planet.

Early Sunday morning, drinking coffee in bed as the gray morning light revealed the outline of the trees and pasture outside my window, I read the Times on my iPad as usual and came across an article titled “What makes people charismatic and how you can be too”.

The article claims that charisma can be learned and cultivated, and that thought resonated with me as I think often about how we as physicians have roles to fill in the stories of diseases and transitions in our patients lives. I try to be the kind of doctor each patient needs as I walk into each exam room.

The article mentions three pillars of charisma: Presence, Power and Warmth.

As I think of my current third guiding light in addition to my medical journals and the New York Times, my DVD collection of the Marcus Welby, M.D. shows, which is shorthand for his character and all the other role models I carry mental images and video clips of, Charisma is definitely something we need to consider and cultivate in our careers.

My job, my reason for being, is to guide and motivate people, and how I come across, how people perceive me, helps determine my chances of filling that role.

So, these pillars of Charisma in the archetypal physician, in my case Marcus Welby, look somewhat like this – first quoting the Times:

“The first pillar, presence, involves residing in the moment. When you find your attention slipping while speaking to someone, refocus by centering yourself. Pay attention to the sounds in the environment, your breath and the subtle sensations in your body — the tingles that start in your toes and radiate throughout your frame.”

Marcus Welby was certainly a keen observer and a good listener. He was also aware of and in tune with his own feelings. Thinking back over my own writing, I recall posts like “The Power of Focus” and “Today’s Masterpiece”. This is about being present so you can connect with each patient, and also so you can do your best under whatever circumstances exist in that moment.

“Power, the second pillar, involves breaking down self-imposed barriers rather than achieving higher status. It’s about lifting the stigma that comes with the success you’ve already earned. Impostor syndrome, as it’s known, is the prevalent fear that you’re not worthy of the position you’re in. The higher up the ladder you climb, the more prevalent the feeling becomes.

The key to this pillar is to remove self-doubt, assuring yourself that you belong and that your skills and passions are valuable and interesting to others. It’s easier said than done.”

I think many of us are afraid to use the power we have and just as the Times article points out, power is not about status; in medicine it is about power to help, fix or influence. Consider their words “assuring yourself that you belong and that your skills and passions are valuable” – Marcus Welby certainly didn’t seem to doubt that when he spoke up to his hospital medical staff or to patients and families. He projected a quiet power and confidence that we, today, as cogs in the big healthcare machine may not always feel that we have. My own writing includes “Where is Relationship, Authority and Trust in Healthcare Today?” and “Getting it Right”.

“The third pillar, warmth, is a little harder to fake. This one requires you to radiate a certain kind of vibe that signals kindness and acceptance. It’s the sort of feeling you might get from a close relative or a dear friend. It’s tricky, considering those who excel here are people who invoke this feeling in others, even when they’ve just met.

To master this pillar, Ms. Cabane suggests imagining a person you feel great warmth and affection for, and then focusing on what you enjoy most about your shared interactions. You can do this before interactions, or in shorter spurts while listening to someone else speak. This, she says, can change body chemistry in seconds, making even the most introverted among us exude the type of warmth linked to high-charisma people.”

Marcus Welby, strict as he could be, exuded a well measured warmth, kindness and relatedness. I have speculated, for example in “Role Play”, that this warmth isn’t necessarily of our own making but emanating from the source of everything, whatever people may choose to call that.

When you get right down to it, I think healthcare providers today are too often viewed by others and increasingly also by themselves as interchangeable. That is the opposite of Charisma. Like so many times before in recent years, I’m puzzled by how everywhere else in our society people and businesses strive to stand out and to establish their constant presence, perceptions of power and warm relationships with their customers, while healthcare professionals are hiding too much behind a vail of sameness and anonymity, seemingly even creating distance and projecting a lack of warmth – almost on purpose in a misguided effort to seem professional?

I Learned a New Word Today: RECRUDESCENCE – NEJM

The New England Journal of Medicine’s question of the week was about an elderly man with a prior stroke history, who during a febrile illness had a temporary recurrence of his original stroke symptoms.

“Patients who have had neurologic deficits as a result of stroke or multiple sclerosis sometimes experience reemergence or recrudescence of those deficits in the setting of an intercurrent illness. The most common triggers include infection, hypotension, hyponatremia, hypoglycemia, insomnia, stress, and benzodiazepine use. Recrudescence occurs most commonly with middle cerebral-artery infarcts and can lead to language, sensory, and motor deficits. Gaze preference, hemianopsia, and neglect are not typically observed.”

Quality is an elusive thing: JAMA Network Open has a piece about what kind of correlation there is between the diabetes quality indicators we all deal with in primary care and what really happens to patients. Any guesses?

In this study, the associations among different types of diabetes quality measures were weak, and much variation in the rates of utilization-based outcomes was unexplained by clinical practice group performance on traditional process and disease control measures. This outcome may be due in part to the topped-out nature of process measures, but the weak association between clinically robust disease control measures and hospitalization rates, the modest difference in hospitalization rates based on process and disease control performance, and the small amount of variation between clinical practice group hospitalization rates explained by process and disease control performance all raise concern about the validity of utilization-based outcomes as a measure of quality in chronic diseases. In chronic diseases such as diabetes, more hospitalizations may not necessarily be evidence of poor outpatient care, which has significant implications for quality-based reimbursement in chronic disease management.

I’m making a plug again for The Lancet, which has lots of free material, available just by registering.

Here’s something so basic we should be ashamed for not making better use of: The FAMILY HISTORY. Now that there are genetic markers and all, why don’t we pay more attention to obtaining a proper Family History?

If applied across the general population, systematic FHH-based risk assessment has the potential to have a substantial effect on population health management. Up to 44% of people meet criteria for increased risk for at least one hereditary condition based on current guidelines, so the potential for impact on health is huge.40 Scaled to a population, FHH becomes a means of assessing the true risk and potential costs that a health system might use to better manage its financial risk. When multiplied to potentially affected family members, the effect becomes even greater.
— Read on www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31275-9/fulltext

I have advocated before for putting a visit synopsis at the beginning of each visit note. I have called that the aSOAP note. I think that works immensely better than APSO notes that only rearrange the order of the elements. The reason I say that is that in today’s EMR notes, it’s too darn hard to find THE STORY. If a note is half a dozen pages or scrolls long, why would I want the medication changes and the reason why they were made at opposite ends of the note? The order means less than the distance between them in my opinion.

The way I approach reading a note is with the two questions “What happened in the last visit?” and “Why was that the clinical decision?” In more and more of my office notes I answer these two questions for future readers, which would include me, in temporal, typographical and spatial connection with each other, right on top.

Let’s face it, how often would it be more useful to try to scan a lengthy Review of Systems and a Comprehensive Exam to find the pertinent positives than to read in the top paragraph that the patient who was placed on a potassium sparing diuretic two months ago and kept rescheduling their followup appointment is now hypotensive and nauseous with an unusually pale complexion and putting out less than normal amounts of urine. Consequently we stopped the medication, sent the patient for STAT labs or to the ER. Seriously, I don’t need to read anything more in that office note: You and I both know this person is in acute kidney failure, caused by the spironolactone. DONT WASTE MY TIME AS A FUTURE READER by mixing those crucial elements with other, less pertinent information. Put it in there, away from the story in case somebody needs to check if we screened for depression or smoking status, but those are filler materials and side plots in this riveting STORY of iatrogenicity.

I admit that in today’s healthcare environment, the office note serves many “stakeholders” (I’m not sure I like that word…), but since I am the clinician who sees the patient, makes treatment plans and then has to follow up on what parts of the treatment plan worked and what parts didn’t, I can’t accomplish anything without the thread of the chain of events I am ending up calling THE STORY. It belongs to the patient, but I’m the one that needs it, desperately sometimes, as even small nuances in the narrative of a life or a disease can change my assessment and the trajectory of care I provide.

And, here’s a confession, if I don’t have time to finish my note in real time, or if (ahem) I’m catching up on a backlog of chart notes, it’s the “a for abstract” segment I focus on; the number of “bullets” and 99213 versus 99214 is not my priority when I’m in survival mode (mine AND possibly the patient’s).

So I am again making the case for a narrative abstract at the top of each office note, an executive summary if you will, just like the world of academic journals has decided to present complex information.

If it’s good enough for The New England Journal of Medicine, it should be good enough for this Country Doctor.

Tomorrow I’ll have another “Medical Monday” talk taped for our local TV station.

It’s set up more like an interview but I still have to prepare it like a talk. It’s a little speech I give to patients several times per week, but it still causes some raised eyebrows, so I think it’ll be useful for a bigger, more general, audience.

I think I’ll say something like this:

The reason you can have a heart attack even after a normal stress test is that it isn’t necessarily the biggest blockages that cause heart attacks.

Big blockages, or plaques, don’t develop overnight. They take a while, and are more likely to either be silent (if other blood vessels take over the blood flow, like when commuters start to choose the side streets because the highway gets too congested) or to cause what we call stable angina.

Stable angina is chest pain after a certain work load, say two flights of stairs but not one.

Big blockages don’t always cause people to have chest pain if they push themselves too hard; diabetics, for example, often don’t feel pain when the heart is suffering lack of oxygen from its diminishing blood supply, because diabetics can have all kinds of nerve damage, not just in their feet.

Medium sized blockages, say 30-50 percent ones, are the scariest ones, because they may not limit blood flow enough to cause EKG changes or any visible decrease in the radioactive glow we measure in a nuclear stress test.

But 85% of all heart attacks happen as a result of plaque rupture. The wall of the plaque breaks and the “gooey stuff”, cholesterol and other lipid particles, oozes out into the blood stream and a clot forms around it. That’s why we give “clot busters”, fast acting blood thinners, to people who are teeter-tottering on a heart attack. This is what we call Acute Coronary Syndrome.

A couple of decades ago, doctors first gave Lipitor to people with Acute Coronary Syndrome and their pain went away. Lowering cholesterol doesn’t happen that quickly, so what was that all about? More on that in a bit.

Of course, big blockages can rupture, but they are more likely to cause warning symptoms before that happens, while the smaller ones are undetectable unless you do a heart catheterization on everybody.

(CT scans can be used to look for calcified plaque, but the non-calcified, softer plaque might actually be more dangerous.)

So, let me come back to he smaller blockages.

The first thing to make clear is that our arteries are not metal pipes, or even plastic tubes. they are living tissue. And just like our skin renews itself every thirty days or so, our arteries are undergoing all kinds of repair and renewal.

One important aspect of how healthy our arteries are is whether there is inflammation, and we are talking coronary arteries here, but the same thing holds true for the blood vessels to our feet and our brains, too.

When there is inflammation in, say a knee or on the skin, there is redness and swelling and all kinds of chemical reactions that work great if you need to heal broken bones or open wounds. But that kind of reaction can also lead to unwanted bone spurs, thick and peeling skin or, in our arteries, plaque formation.

And sure enough, people with inflammation, be it rheumatoid arthritis or chronic gum infections, on average have more plaque and more heart attacks than you would expect from looking at just the classic list of risk factors, like blood pressure and cholesterol.

Another alarming tidbit here is that some foods cause inflammation, like sugars and refined carbohydrates, while other foods like fish and olive oil reduce it.

In addition to lipid blood testing for determining heart attack risk, we sometimes use blood tests we call “inflammatory markers” (one of them is CRP, or C-Reactive Protein) to decide who should take drugs to lower their heart attack risk.

And this is where Lipitor, now generic atorvastatin, comes in.

It was one of many “statin” drugs developed for lowering harmful LDL cholesterol. It also lowers inflammatory markers in the blood, and as we found out after years of study, it decreases, and in high doses it can even reverse, plaque buildup in the neck arteries as measured by ultrasound, and it can reduce heart attack and stroke risk by 30-50%.

There are other, non-statin drugs (like Zetia), that lower cholesterol and inflammatory markers, but have nowhere near the impact on heart attack risk that the statins have.

So what’s going on?

We now know that Lipitor and the other statins actually do five things:

1) THEY LOWER CHOLESTEROL AND LDL, and that means something but is probably not their main action.

2) THEY MAKE THE PLAQUE WALL LESS BRITTLE, LESS LIKELY TO RUPTURE.

3) THEY PREVENT PLAQUE BUILDUP AND CAN SHRINK EXISTING PLAQUE.

4) THEY HAVE ANTI-CLOTTING PROPERTIES THAT ARE DIFFERENT FROM THE WAY ASPIRIN WORKS.

5) THEY RELAX THE LITTLE MUSCLES IN THE WALLS OF OUR ARTERIES THAT CAN CAUSE “CORONARY SPASM”.

The second through fifth of these mechanisms are well known by now, but we can’t measure them, so people still spend a lot of attention on the numbers that we can measure.

And speaking of measures: In 2013 the American Heart Association and the American College of Cardiology issued a new lipid guideline, with an update added this past year.

Instead of dividing people into just high, medium or low risk for heart disease, the new guideline has a calculator that lets you figure out somebody’s ten year risk. You can then compare this to the best case scenario, and also see what the impact would be of treating blood pressure, quitting smoking or taking Lipitor.

Now, I don’t mean to be overly enthusiastic about Lipitor. It can have unwanted side effects, from brain fog to rising blood sugars to muscle aches. But I am enthusiastic about how much better we understand how heart disease develops.

And I am also excited about what other research has shown: Our diet and lifestyle can address the same five mechanisms of action that Lipitor does. There is more and more proof that avoiding junk food and soda, following a plant based OR a Paleo OR Mediterranean diet, being physically active, sleeping well, managing stress and so on, can have the same impact and reduce a person’s heart attack risk by half.

I’m sure there will be reasons to ad-lib, answer questions, go in depth or off on tangents, but this is the framework I’ll start out with.

I learned in medical school (1974-79) that white coat hypertension was not clinically important and should not be treated. Somewhere along the line I was also told that people with little variability in their blood pressure fared less well than people whose blood pressure varied according to their circumstances.

As late as 2008, articles were pointing out that awareness of these phenomena could avoid misdiagnosis and unnecessary treatment.

White coat hypertension is an important clinical problem given its potential to result in misdiagnosis and possibly inappropriate drug treatment. Although ambulatory and home BP measurements are more accurate and predictive of target organ damage, physicians’ office measurements continue to be the criterion standard. That being the case, the sources of measurement error that occur in the office setting remain an impediment to the accurate diagnosis and treatment of hypertension. Data from several studies show that who takes the BP and how it is taken (ie, by a person or an automated device) have a substantial effect on the measurement.24 Our findings indicate that measurements taken by physicians appear to exacerbate the white coat effect more than other means. We suggest that one way of addressing this problem is to modify the method by which BP is measured in the office setting given the wide availability of reliable and validated automated BP monitors that are suitable for both office and home use. Similarly, home BP monitoring has been shown to predict target organ damage as well as (or better than) ambulatory monitoring25 and, thus, is superior in this regard to traditional office measurements. Thus, BP taken by an automatic device, while the patient is alone in the physician’s office, may provide the best means of avoiding a hypertension misdiagnosis.
— Read on jamanetwork.com/journals/jamainternalmedicine/fullarticle/773457

In June of this year, the Annals of Internal Medicine published a widely cited paper that demonstrated that people with white coat hypertension (WCH or WCHT) have up to twice the death rate of people who don’t have it.

“Untreated WCH, but not treated WCE, is associated with an increased risk for cardiovascular events and all-cause mortality. Out-of-office BP monitoring is critical in the diagnosis and management of hypertension.”

An old article I found explains that white coat elevations can be transient or sustained and can happen in people with or without hypertension. So what the Annals authors mean by “treated WCE” confuses me. If a white coat elevation is sustained, isn’t that the same as white coat hypertension?

White coat hypertension (WCHT) and white coat effect (WCE) are often thought to be of the same entity. They are in fact different conditions which carry distinctive definitions and prognostic significance. WCHT is diagnosed when office blood pressure (OBP) is ≥140/90 mmHg on at least 3 occasions, while the average daytime or 24-hour blood pressure is <135/85 mmHg. It is common with 15% prevalence in the general population and may account for over 30% of individuals in whom hypertension is diagnosed. Although individuals with WCHT were reported to have a better cardiovascular (CV) prognosis when compared to those with sustained hypertension and masked hypertension; they were also shown to have a greater prevalence of target organ damage (TOD) and metabolic abnormalities than that of normotensive subjects. In contrast, WCE is defined as the transient elevation of OBP induced by the alerting response to a doctor or a nurse. WCE can occur in both normotensive and hypertensive
— Read on www.ncbi.nlm.nih.gov/pmc/articles/PMC4170363/

Nevertheless, the most recent piece published on this topic reveals that not only 24 hour measures of blood pressure determine outcomes, but nighttime blood pressure does to the same degree.

“In this population-based cohort study, higher 24-hour and nighttime BP were significantly associated with greater risks of death and a composite cardiovascular outcome, even after adjusting for other office-based or ambulatory blood pressure measurements.“

It wasn’t even nine o’clock when the screen on my laptop suddenly froze. From that moment until my last patient left the building, my clinic had no Internet.

For my part, the day went pretty smoothly, mostly because of some of my own work habits. It also helped that it was a warm, sunny day and my schedule was on the light side. Others have frowned at my old-fashioned work habits, but this is what I do:

PRINTING THE LAST OFFICE NOTE

For all pre-booked visits, we print the last office note. We also print important lab results and outside reports. One reason is that I may give these to the patient. The other is that when you create an office note and need to incorporate what happened in the ER or hospital, what the MRI showed and so on, the EMRs I have worked with don’t easily allow me to read the source document and type/dictate my own note in a split screen. And since interoperability is just a theoretical concept most of the time, I cannot import or cut and paste from outside sources.

Having the last office note printout gives me a reminder of what happened, the medication and allergy lists, all kinds of information that helps me move quickly through an Internet blackout day.

MY WORK SHEET

I don’t know what life would be like without this paper, which has gone through a few renditions over the years. It lets me quickly jot down important parts of my patient’s history and exam, what tests I need to order, what referrals I need to make and all kinds of things which in theory would be super quick to do with a computer but unfortunately aren’t.

At the end of the day yesterday, I copied these sheets, left the originals with my medical assistant and brought the copies home, so that on my day off (who pays the price for a computer failure?) I can finally enter the lost visits into the system while the office schedules the followup appointments and things like that.

Ironically, I have been toying with the idea of making an update to my work sheet, inspired by old rheumatology notes I used to see; they had a drawing of a body with each joint made into a stylized box for notations about which joints were affected by disease.

My recent thought has been to put a picture of a body on my sheet with simple indicators for things like, how much edema, size of a lesion, grade of murmur and so on…

Here is my work sheet in its current form. It saved the day for me yesterday:

Where Have All The Young Docs Gone? – NEJM

The New England Journal of Medicine published a sobering piece about the rapid changes in age distribution among rural physicians. They also point out that the aging and chronic disease burden of the US rural population is expected to increase demand for rural medical providers.

“Maintaining physician supply in rural areas has important equity implications, given that, as compared with more urban populations, rural residents are likely to be older and poorer, are more commonly uninsured, and have lower life expectancy.”

The article by Skinner et al makes a few suggestions about what to do to forestall what they describe as an evolving crisis, from loan repayment to hiring more Nurse Practitioners.

I think these types of strategies are unlikely to reverse what is a bigger trend in our society. As a 66 year old physician moving back to Caribou, Maine, I see the challenges of my community all around me: A more than half empty shopping mall in Presque Isle, the closing of a 100 employee customer service call center in Caribou, the empty store fronts lining Main Street in Van Buren. It isn’t just the physician work force that is changing, de demographics of rural America are changing.

It’s strange in a way, when our world is increasingly well connected and distances appear to mean less and less (if only my Internet connection were better and less expensive…) why being physically located in an urban area is so attractive.

In rural New England people don’t need to lock their cars or their houses, they don’t have to stand in line, sit in traffic or feel crowded by the noise around them. But they do need jobs that pay a decent wage. That’s the problem here. Fix the economy (if you can) and the health disparities will diminish.

As the number of younger physicians entering rural practice has declined, the rural physician workforce has grayed. By 2017, more than half of rural physicians were at least 50 years old, and more than a quarter were at least 60. In contrast, the number of urban physicians under 50 grew 12% from 2000 to 2017, and in 2017 only 39% of urban physicians were 50 years of age or older and only 18% were at least 60.
— Read on www.nejm.org/doi/full/10.1056/NEJMp1900808

————–

Switch

Moving into my new home office I constantly run into books I bought and read years ago but have thought little of since. One book I haven’t read since I first bought it but often keep referring to is “Switch” by Chip and Dan Heath. Subtitled “How to change things when change is hard”, the book has given me a lot to think about as a doctor, whose job often involves trying to cause my patients to change for the purpose of achieving better health.

The three steps to consider when asking someone, even yourself, to change are described, metaphorically as:

1.) Direct the rider. This is what we doctors usually try to do when we tell our patients to eat less, exercise more or take their pills every day.

2.) Motivate the elephant. This is harder, because it involves addressing the subconscious, which cares very little about things like logic or what’s best for us.

3.) Shape the path. If we make it easier somehow to do the “right” thing than the “wrong” thing, people are more likely to do it.

The book has illustrations from all walks of life, from health care to teaching to sales. And, after all, practicing medicine is part teaching and part sales, too.

The central idea for me is how necessary it is to understand and communicate with the elephant, the Heath brothers metaphor for our subconscious. I guess moving our subconscious is not only like riding an elephant, but also a lot like moving horses into a new environment.

I can’t just tell these guys what I would like them to do, I have to find ways to motivate them that are natural for them, that they might want to do in some fashion anyway.

The notion of shaping the path is something I also keep coming back to. So many times we hear that people just aren’t doing what they’re supposed to do, when in fact we are being asked to do things that seem awkward, silly or even impossible.

The recent Boeing crashes due to a software redesign that may have looked good on paper but didn’t make any sense to airline pilots comes to mind.

Similarly, in my world, the “work flows” of modern EMRs may look all right to a computer programmer, but make little sense to health care personnel.

So often in our culture, people are blamed for things that are systems problems and not people problems at all.